What is the management of hiccups after an episode of vomiting (emesis)?

From the Guidelines

To manage hiccups after a single episode of vomiting, try simple physical techniques first, such as taking slow, deep breaths, holding your breath for 10-20 seconds, or sipping cold water slowly, as these methods are non-invasive and can help stimulate the vagus nerve to stop hiccups. Hiccups after vomiting are usually temporary and caused by irritation of the diaphragm or vagus nerve from the forceful contraction during vomiting 1. Most cases resolve within minutes to hours without treatment. If these physical techniques don't work, try swallowing a teaspoon of granulated sugar, which may irritate the throat enough to interrupt the hiccup reflex. For persistent hiccups, over-the-counter medications like simethicone (Gas-X) may help if gas is contributing to the problem. It's essential to note that while antiemetic therapy is crucial in managing nausea and vomiting, as discussed in the guidelines for chemotherapy- and radiotherapy-induced nausea and vomiting 1, the primary focus for hiccups after vomiting should be on relieving the hiccup symptom directly rather than solely addressing the vomiting. If hiccups persist for more than 48 hours or are accompanied by severe abdominal pain, difficulty swallowing, or shortness of breath, seek medical attention as this could indicate an underlying condition requiring treatment.

Some key points to consider in managing hiccups after vomiting include:

• The importance of initial non-invasive physical techniques to stimulate the vagus nerve and stop hiccups.
• The potential use of over-the-counter medications for persistent hiccups, especially if gas is a contributing factor.
• The distinction between managing hiccups and managing nausea and vomiting, although both can be interrelated in the context of chemotherapy or other medical treatments 1.
• The need for medical evaluation if hiccups persist or are accompanied by other severe symptoms, indicating a possible underlying condition.

Given the information from the studies on antiemesis and the management of nausea and vomiting 1, the approach to hiccups after a single episode of vomiting should prioritize simple, non-invasive methods first, with medical evaluation and potential intervention if the condition persists or worsens.

From the FDA Drug Label

For relief of intractable hiccups

• Chlorpromazine (PO) can be used for the management of intractable hiccups 2.
• The drug label does not specify the management of hiccups after vomiting, but it does mention relief of intractable hiccups.
• Chlorpromazine (PO) may be considered for hiccups management after vomiting, but the evidence is not directly related to this specific scenario.

From the Research

Hiccups Management

• Hiccups can be a common and usually benign phenomenon, but persistent or intractable hiccups can be debilitating and may indicate an underlying pathological process 3.
• The treatment of hiccups should be directed at the underlying cause whenever possible, and may include lifestyle changes, physical maneuvers, pharmacotherapy, and rarely, surgical intervention 3.

Pharmacologic Interventions

• Chlorpromazine is the only drug approved by the US Food and Drug Administration for the treatment of hiccups, but many other pharmacologic treatments have been proposed for intractable and persistent hiccups 4.
• Metoclopramide has been reported to have effects on intractable hiccup, and its effectiveness and safety are being studied in a systematic review and meta-analysis 5.
• Other pharmacologic agents that have been found to be successful in treating hiccups include amitriptyline, baclofen, gabapentin, haloperidol, midazolam, nifedipine, nimodipine, orphenadrine, and valproic acid 4.

Etiologies and Triggers

• Overdistension of the stomach is the most commonly identifiable cause of acute hiccups, followed by gastroesophageal reflux and gastritis 3.
• Persistent or intractable hiccups can be caused by underlying gastrointestinal, neurological, cardiovascular, pulmonary, infectious, and psychogenic disorders 3.
• Vomiting may be a trigger for hiccups, but the exact relationship between vomiting and hiccups is not well understood and requires further study.

Treatment Approaches

• For acute hiccups, treatment may not be necessary as they usually resolve within minutes, but for persistent or intractable hiccups, treatment should be directed at the underlying cause whenever possible 3.
• A detailed history and thorough physical examination may provide clues for the etiology of the hiccups, and treatment modalities may include lifestyle changes, physical maneuvers, pharmacotherapy, and rarely, surgical intervention 3.